Present the case scenario
Allow time for students to think and consolidate their thoughts. Their silence
might mean they are
thinking.

Initiate discussion by asking the Trigger
question:
"How would you like to approach this case?" Allow students to
think loud. Do not interrupt while they are talking.
Simply keep the discussion going by
asking..
What do you think about the suggestion of (Name of
student)?
Do you agree with ( Name of student
)? What
are your thoughts about this issue , ( Name of student)
? Does
everybody agree with the approach we shall take?

STEP 2

Trigger the discussion on the
pathophysiology Encourage them to list LEARNING
ISSUES Encourage the students to use the blackboard to
illustrate their
point. This helps consolidate their thoughts.

STEP 3

Trigger the discussion back to the patient. Ask for
the
Differential
Diagnosis. Encourage the listing of the differential diagnosis
based on
the
mechanism rather than on the disease
entities.
e.g. Mechanism of Edema

STEP 4

Based on the listed differential- trigger the
students to ask for
additional
information from the history or PE that will help rule in or rule
out their
differential diagnosis

STEP 5

Based from the information gathered, trigger the
student to
validate their
hypotheses. Help them focus on the important cues-by asking them
to come up with
the list of important cues in the history and PE

STEP 6

Challenge the students to make the
diagnosis Encourage them to make more LEARNING ISSUES
by challenging
some other issues not in their list? E.g. Why is there no ascites
here? Ask the student to synthesize the whole discussion in a
few words.

STEP 7

Close the session. Ask students to critic
themselves. Comment on how they could have done
better.

Appreciate students who have done
well. Point out politely the weakness of some.(E.g.some who are quiet) Assign
the learning issues by requesting for volunteers who will look into the matter
more in-depth. Volunteers are better than topics being assigned to
students. Agree on the schedule for the next meeting. Advise students to
come back with prepared audiovisuals (sketches or diagrams) and to
provide their classmates a copy. Their sharing should not be more than 2
minutes. It has to be brief, concise and direct to the point. They are to
provide the source of their reading material as well.

SESSION 2

STEP 1

Reconvene the students after their SDL
period

Ask one student to review the case and the
issues discussed in the previous session. Ask students to
share their discovery on the learning issues assigned, and to discuss or
share them not more than 2 minutes each . This will help students to
focus on important issues only and to discard unnecessary information in their
sharing.

Encourage reactions from the rest of
the students.

STEP 2

Professional skills (ex. Abdominal
Examination)
Demonstrate how to do a Abdominal Physical
examination Test
for Ascites Test
for blood flow in assessing superficial abdominal vein
engorgement Have them do a return demonstration of
the procedure and critic their skills

Radiological
Evaluation
X-ray of the abdomen -
Plain
Point the landmarks Venogram of the inferior vena cava. If not
available use diagrams

SESSION 3

STEP 1

Assign students to patients in the hospital or OPD
with similar complain as the module case. Allow the
students to do PE and history taking from a real patient Have a
bedside conference with the student, demonstrating the skill of PE & History
taking Have the students return demo Convene
students in a separate room, & have them critic each others'
skills. Ask students to submit a case report complete with
discussion (see
standard format)

SAMPLE CASE

CLINICAL PRESENTATION

An elderly man presenting
with edema of the lower extremities and back with prominent superficial veins of
the lower limbs, abdominal wall and thoracic
wall.

HOW TO OPEN THE DISCUSSION

How would you like to approach
discussing this case?

Are there any other
alternative approach that you have in
mind?

Why do you prefer to approach
this case this way?

HOW TO TRIGGER DISCUSSION ON PATHOPHYSIOLOGY OF
EDEMA?

What is Edema? What causes Edema? What are
the forces that causes fluid
shifting from the intravascular to interstitial ?
Why don't we list them in the board while we rationalize the
mechanisms for each of the
causes?

HOW TO TRIGGER DISCUSSION ON DIAGNOSIS?

Based on the causes of edema, what
would your differential diagnosis be? What other
information in the history or PE do you wish to
know? Why did you want to know that information? How
will that help in
the diagnosis of this
case? Why was there edema of the LE and superficial
vein engorgement of the Abdomen and chest wall
but no ascites?

HOW TO TRIGGER CONSOLIDATION OF THE
DISCUSSION

Let us synthesize the case: What were
the important critical points
of this case. List them down in the board.
Out of these issues, what cues would you consider strongly to
help you make the
diagnosis? Based on the added information from the History
and PE, how would Validate your differential
diagnosis?

HOW TO TRIGGER DISCUSSION ON THE ANATOMICAL BASIS

How was the venous blood from the lower half of the body able to
by pass the obstruction in the inferior vena
cava?

Would you expect that deep veins as
well as superficial veins be involved?

What are the superficial veins
involved? Which are the deep veins involved?

Review the tributaries of
the inferior vena cava and the anastomotic connections that would allow the
necessary collateral circulation in this case.

What
specific characteristic of the development of this condition prevented a more
serious or perhaps disastrous crisis to the patient?

Would the
occlusion be more serious at the level of the Lumbar Vertebrae 1 or
higher?

What additional problems would you expect to observe if the
obstruction were at the level of LV-1 ?